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‘Pain is not the only problem’: Sagittality

Sagittal Plane Overuse Syndrome (SPOUS, Dean 2006) is defined as the chronic central activation of sagittal plane motor mechanisms to accomplish daily activities, resulting in soft & hard tissue injury, and plastic changes (osseous, neural, motor) that support primarily sagittal plane movement patterns.

Everyday life actions can be expanded into several categories: daily activities, work duties, exercise & training, sports, hobbies, leisure, and family & personal care. These categories describe segments of the patient/athlete’s day, each segment with its own demands on their body; a daily history that embeds itself in the archived relationship of action meeting with demand. In a snapshot, these actions include: standing, sitting, walking, running, taking stairs, bending, reaching, reading, cleaning, dressing, grooming, eating, driving, cooking, sleeping… activities that primarily occur in the sagittal plane of the head, neck, shoulder, spine, hip, knees, and ankles.

Cardio exercise machines (treadmill, elliptical, rower, cycles, stair steppers) engage only the sagittal plane of action. Gym exercise equipment is also designed primarily to engage the sagittal plane of action, and commonly requires both limbs to act together; arms push or pull together, legs push or pull together.

Considering daily activities combined with exercise, the sagittal plane is the most recruited plane of motion. The transverse plane and frontal plane contribute literally nothing to the patient/athlete’s everyday actions and training, putting an enormous imbalance in all-body recruitment. However, all three planes of motion (four if you include axial compression; GFR, five if you include distraction) are important to provide variety to the human action experience. A spine that is only activated in the sagittal plane, and minimally in rotation or lateral bending, will be experiencing only 1/3 of its potential. This is a dangerous situation, since a ‘sagittal spine’ will not be able to activate effectively nor efficiently when it is required to also perform in rotation or lateral bending. It is important to clarify a specific point; sagittal plane action is purely sagittal, but what we are interested in is sagittal plane action combined with rotation and lateral bending in the endless possible combinations of multiple-planes and multiple directions.

It is naïve to expect a ‘sagittal spine’ to perform in planes of motion for which it has no experience, and this creates 2 problems, (1) the motor relationship between the sagittal spine with rotation/lateral bending is undeveloped, and therefore injury is eminent, (2) the proprioceptive relationship between central processing with rotation and lateral bending is undeveloped, and therefore injury is eminent.

Motor relationships and proprioception are learned, not intrinsic; motor relationships rely on ‘patterns’ that require repetition and practice. Motor patterns are sequences; if a component of the sequence is missing, there is no sequence, and therefore there is eminent strain, stress, and injury. Absent planes of motion break the sequence, and the outcome is always the same, a faulty motor pattern.

Acutely, persistent sagittal action may cause annoying back pain, shoulder and neck strain. Or, there may be no presenting symptoms, as in the case of STMT. This acute exacerbation might be termed ‘Sagittitis or, with pain Sagittalgia.’ With time, it is possible that the patient’s body will deform into the sagittal plane, as demonstrated in Upper & Lower Cross Syndromes, and acquired kyphosis. The chronic condition might be termed ‘Sagittosis.’

It is pertinent that the clinician evaluates the ‘sagittality’ of the patient/athlete’s everyday activities. If the clinician simply asks the patient if they get 30 minutes of daily activity, the clinician might be missing the possibility that the patient’s LBP might be largely due to an absence of mixed-plane activity, since ‘pain is not the only problem.’

LBP Blog General information

Series Description

These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.

Dr. Dean Bio

Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020.

© Copyright 2021 SpineSync, Forester Dean, DC
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